Intimate Partner Violence and Incident Depressive

Symptoms and Suicide Attempts: A Systematic Review of

Longitudinal Studies
Karen M. Devries1*, Joelle Y. Mak 1, Loraine J. Bacchus 1, Jennifer C. Child 1, Gail Falder 1, Max Petzold 2,
Jill Astbury3, Charlotte H. Watts1
1 London School of Hygiene & Tropical Medicine, London, United Kingdom, 2 University of Gothenburg, Göteborg, Sweden, 3 Monash University, Clayton, Australia

Abstract
Background: Depression and suicide are responsible for a substantial burden of disease globally. Evidence suggests that
intimate partner violence (IPV) experience is associated with increased risk of depression, but also that people with mental
disorders are at increased risk of violence. We aimed to investigate the extent to which IPV experience is associated with
incident depression and suicide attempts, and vice versa, in both women and men.

Methods and Findings: We conducted a systematic review and meta-analysis of longitudinal studies published before
February 1, 2013. More than 22,000 records from 20 databases were searched for studies examining physical and/or sexual
intimate partner or dating violence and symptoms of depression, diagnosed major depressive disorder, dysthymia, mild
depression, or suicide attempts. Random effects meta-analyses were used to generate pooled odds ratios (ORs). Sixteen
studies with 36,163 participants met our inclusion criteria. All studies included female participants; four studies also included
male participants. Few controlled for key potential confounders other than demographics. All but one depression study
measured only depressive symptoms. For women, there was clear evidence of an association between IPV and incident
depressive symptoms, with 12 of 13 studies showing a positive direction of association and 11 reaching statistical
significance; pooled OR from six studies = 1.97 (95% CI 1.56–2.48, I2 = 50.4%, pheterogeneity = 0.073). There was also evidence of
an association in the reverse direction between depressive symptoms and incident IPV (pooled OR from four studies = 1.93,
95% CI 1.51–2.48, I2 = 0%, p = 0.481). IPV was also associated with incident suicide attempts. For men, evidence suggested
that IPV was associated with incident depressive symptoms, but there was no clear evidence of an association between IPV
and suicide attempts or depression and incident IPV.

Conclusions: In women, IPV was associated with incident depressive symptoms, and depressive symptoms with incident
IPV. IPV was associated with incident suicide attempts. In men, few studies were conducted, but evidence suggested IPV
was associated with incident depressive symptoms. There was no clear evidence of association with suicide attempts.
Please see later in the article for the Editors’ Summary.

Citation: Devries KM, Mak JY , Bacchus LJ, Child JC, Falder G, et al. (2013) Intimate Partner Violence and Incident Depressive Symptoms and Suicide Attempts: A
Systematic Review of Longitudinal Studies. PLoS Med 10(5): e1001439. doi:10.1371/journal.pmed.1001439
Academic Editor: Alexander C. Tsai, Massachusetts General Hospital, United States of America
Received October 26, 2012; Accepted March 22, 2013; Published May 7, 2013
Copyright: ß 2013 Devries et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was funded by ESRC EOA RES-189-25-0198 to C. Watts. The funders had no role in study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
Abbreviations: CES-D, Center for Epidemiologic Studies Depression Scale; CSA, childhood sexual abuse; IPV, intimate partner violence; OR, odds ratio; SRQ-20,
Self-Report Questionnaire–20.
* E-mail: karen.devries@lshtm.ac.uk

PLOS Medicine | www.plosmedicine.org 1 May 2013 | Volume 10 | Issue 5 | e1001439


Background
Unipolar depressive disorders are the second leading cause of
disease burden in women aged 15–44 y worldwide, and self-
inflicted injuries are the seventh leading cause of disease burden
[1]. Intimate partner violence (IPV) is also common, being
reported by 15%–71% of women over their lifetime [2]. These
conditions are linked—IPV experience is strongly and consistently
associated with depression, including depressive symptoms and
depressive disorders, and suicide in cross-sectional studies of
women in both high- and lower-income settings [3–7]. There is
less research on men, but cross-sectional studies also show that
depressive symptoms are associated with IPV experience [8].
Several authors have speculated that the increased exposure to
various forms of violence among women relative to men may help
to explain the greater prevalence of depression, suicide attempts,
and other common mental disorders in women versus men [9,10].
While it is easy to assume that IPV is causally related to
subsequent depression and suicidal behaviour, evidence suggests a
more complex relationship. There are three modes of association,
which are possible in any combination: (1) IPV exposure causes
subsequent depression and suicide attempts, (2) depression and/or
suicide attempts cause subsequent IPV, and (3) there are common
risk factors for both IPV and depression and suicide attempts that
explain the association between them.
Traumatic stress is the main mechanism by which IPV might
cause subsequent depression and suicide attempts. Traumatic
events can lead to stress, fear, and isolation, which in turn may
lead to depression and suicidal behaviour [9]. A recent meta-
analysis of three longitudinal studies provides support for this
direction of association with depression, but this analysis pooled
depressive disorders, depressive symptoms, and postpartum
depression; included only a subset of known studies; and examined
only one direction of association (that IPV is a risk factor for
depression) [5]. To our knowledge there are no meta-analyses of
the associations between IPV and suicide attempts.
Conversely, other studies suggest that women with severe
mental health difficulties are more likely to experience violent
victimisation [11,12]. The same may hold for more minor forms of
depression. Studies among US teenagers suggest that depression
precedes first incidents of dating violence [13]. It is plausible that
depressive symptoms may influence partner selection, such that
young men and women are more accepting of partners with poor
impulse control, conduct disorders, or other factors that predispose
partners to use violence. Although it is clear that violence must
precede completed suicides, most studies on violence and suicide
actually measure suicide attempts, which could precede violent
experiences.
Developmental and early life exposures to violence and other
traumas may also play a role in predicting both violence and
depression, for example, by contributing to the formation of
insecure or disorganised attachment styles, which are associated
with both increased IPV and depression risk [14,15]. Although the
mechanism remains unclear, women who have experienced
childhood sexual abuse (CSA) also have an increased risk of
subsequent experience of IPV [16]. Usually, longitudinal twin
studies provide the best means of ruling out the confounding effect
of early life factors, and two twin studies that have investigated
exposure to general trauma suggest that traumatic events are
causally associated with increased risk of major depressive disorder
and suicide [9,10,17,18]. However, to our knowledge no twin
studies have examined the role of IPV victimisation specifically.
PLOS Medicine | www.plosmedicine.org
Intimate Partner Violence, Suicide, and Depression
To assess the magnitude and direction of the relationship
between IPV and depression and suicide attempts, we conducted a
systematic review and meta-analysis of longitudinal studies
examining the association of depression and suicide attempts with
IPV experience in women and men. This study was conducted as
part of the work of the Expert Working Group on Violence, for the
Global Burden of Disease Study 2010 [19]. We aimed to (1)
describe the characteristics of included studies, (2) report on
magnitude and direction of association, and (3) document and
explore potential sources of heterogeneity.
Methods
Searches
We searched 20 different health and social science databases,
including Medline, Embase, CINAHL (Cumulative Index to
Nursing and Allied Health Literature), and region-specific
databases from first record until February 1, 2009. This initial
search was conducted as part of a larger set of systematic reviews,
and included studies looking at health conditions in addition to
depression and suicide. We updated the search in Medline to
February 1, 2013, focusing on only depression and suicide studies.
Strategies were designed in consultation with a librarian.
Controlled vocabulary terms related to study design, violence,
depression, and suicide were used for each database. The search
and screening process is summarised in Figure 1. A list of
databases and an example search strategy are provided in Text S2,
and a PRIMSA checklist in Text S1.
Inclusion Criteria
Longitudinal studies in any population of male and/or female
participants were considered. Studies were deemed longitudinal if
either the exposure or the outcome was measured at more than
one time point. Papers reporting data from existing cohorts where
both the exposure and outcome were assessed at the same time
point were not included. All author definitions of IPV experience
and all author definitions of depression (including symptoms and
diagnoses) and measures of suicide attempts were eligible for
inclusion. Papers reporting only on postpartum or antenatal
depression were not included. Papers reporting only on suicidal
thoughts or plans were not included.
Screening and Data Extraction
For the original search, abstracts were screened by one
reviewer; full text articles were appraised by JM, JC, GF, or LB
and re-appraised by KMD. Data were extracted by one reviewer
(JM, JC, GF, or LB) onto a standardised form, and checked by
KMD. For the update, all steps were performed by KMD.
Information about study population, exposure and outcome
definitions, length of follow-up, effect estimates and uncertainty,
analysis and control for confounding, and study quality were
extracted.
Quality Assessment
We appraised the quality of each effect estimate. We considered
the definitions of the violence and depression/suicide measures
and whether these were measured using valid, reliable instru-
ments. We considered how the reference groups for each exposure
were constructed (if they were truly unexposed or if there could
potentially have been some misclassification). This is especially
important for research examining the effects of IPV, as different
forms of IPV (physical and sexual) are often only moderately
correlated [2]. Studies measuring only one form of violence
2 May 2013 | Volume 10 | Issue 5 | e1001439

Figure 1. Flow of studies through the review.
doi:10.1371/journal.pmed.1001439.g001
therefore potentially have a comparison group with exposure to
the other form of violence.
We also considered control for potential confounders in key
areas. First, because both IPV and depression commonly occur
episodically over a period of time, events of either that are incident
over the study period could be a continuation of previous
violence/depression. Thus, we examined whether time one levels
(at the beginning of the study period) of the outcome variable were
adjusted for. Second, both IPV and depression/suicide attempts
are associated with childhood adverse events, substance use,
demographics, and other common risk factors that may explain
the association between them. Because of the complexity of the
potential causal pathways involved, we did not define a minimum
set of confounders or common risk factors that should be adjusted
for, but we aimed to consider results in light of which variables
were included in analyses.
Data Synthesis
Overall results on study characteristics and quality are
summarised descriptively. Studies reported a range of different
types of effect estimates (for example, relative risks, odds ratios
[ORs], and correlation coefficients). They also varied on whether
violence and depression outcomes were measured as binary or
continuous variables, making it difficult to quantitatively summa-
rise results. Where information was not reported, we calculated
effect estimates and uncertainty as far as possible. Therefore, we
present (1) results of all studies meeting the inclusion criteria in
PLOS Medicine | www.plosmedicine.org
Intimate Partner Violence, Suicide, and Depression
their original metrics in tabular format, and (2) where possible,
pooled measures of effect using random effects meta-analysis.
Heterogeneity was measured using Higgins I2, with p,0.10 taken
to indicate possible heterogeneity. For each meta-analysis, only
one estimate per data source was included. The estimate least
subject to bias according to the quality criteria above was selected.
We had too few studies to quantitatively examine sources of
heterogeneity.
Ethics Statement
All data used in this review were already in the public domain;
no ethical approval was required.
Results
Study Characteristics
Sixteen studies with 36,163 participants met the inclusion
criteria. These were reported in 17 papers and contained 55
relevant effect estimates. Ten of these studies were from the US,
two from Australia [20,21], one from Sweden [22], one from India
[23], one from Nicaragua [24], and one from South Africa [25].
Three studies from the US [13,26,27] included adolescents and
focused on dating violence; all of the other studies focused on IPV
in adults. Four studies sampled participants from secondary
schools [13,22,26,27], four studies were individual or household
surveys of the general population [20,21,23,28], one was
conducted at a college [29], one was conducted among hospital
employees [30], and three sampled from a variety of venues
3 May 2013 | Volume 10 | Issue 5 | e1001439

[25,31,32]. The three remaining studies recruited pregnant
women, two from hospitals [33,34] and one from households in
the general population [24]. Details of study characteristics are
described in Table S1.
The median follow-up time was 36 mo (interquartile range 12–
60 mo) (range 2 mo [29] to 14 y [31]). Median attrition rate was
22.5% (interquartile range 17%–28.6%) (range 4.5% [31] to
57.1% [34]). Ten studies made use of two waves of data collection,
two had three waves [23,34], two had four waves [26,30], one had
five waves [33], and one had 14 [31]. The majority of studies
included only female participants; the four studies that recruited
from secondary schools also included males.
IPV measurement and potential misclassification. Nearly
all (14 of 16) studies used measures of experience of specific
acts of violence based in whole or in part on the Conflict
Tactics Scale [35] or the World Health Organization
instrument [24,25]; one was based on the Abuse Assessment
Screen [30] and one on the Severity of Violence Against
Women Scales [33]. All of these instruments measure self-
reported experience of specific acts of violence, for example,
‘‘Have you ever been slapped, punched, kicked, hit with an
object’’, and so on. Although measuring specific acts avoids
misclassification associated with participants having different
perceptions of whether what they have experienced constitutes
‘‘violence’’ or not [2], nearly half of all studies (six studies;
seven papers) measured exposure to physical violence or sexual
violence only [13,28,29,31,36,37], leaving open the possibility
of substantial misclassification of total violence exposure.
Loxton et al. asked only if the respondent had ‘‘been in a
violent relationship with a spouse’’ [20] and Jonsson et al.
asked if participants ‘‘had ever been physically abused or had
their life threatened’’ [22].
Depression
Sixteen studies (reported in 17 papers—two papers used data
from Add Health [13,37]) provided 47 estimates of association
between IPV and depressive symptoms or disorder. Forty-one
estimates from 16 studies were for women, and six estimates from
four studies were for male populations. Taking only the least
biased estimate from each study gives 23 estimates from 16 studies.
These 23 estimates are outlined in Table 1 and considered below;
more detailed study information, including other effect estimates,
is presented in Table S1.
Depression measurement. Of the 16 studies included,
eight measured depressive symptoms over a defined time period
(five were over the 1 wk prior to the survey, three were over the
past year, and the remainder did not specify). Seven studies used
the Center for Epidemiologic Studies Depression Scale (CES-D)
[13,20,21,25,28,30,36], two used the Beck Depression Inventory
[29,33], one used the Self-Report Questionnaire–20 (SRQ-20)
[24], one used the Brief Symptom Inventory [31], one used the
Composite International Diagnostic Interview–Short Form [34],
one used a scale from K. S. Kendler [26], and one used a scale
from D. B. Kandel and M. Davies [27]. The one study that
measured incident depressive disorders [23] used the Clinical
Interview Schedule–Revised. Jonsson et al. used the CES-D and
Beck Depression Inventory but also the Diagnostic Interview for
Children and Adolescents–Revised–Adolescents and the Mini-
International Neuropsychiatric Interview. All measures were
combined for analysis [22].
Common risk factors/confounding. Of the estimates for
women, presented in Table 1, most were adjusted for time one
measures of the outcome, but five estimates were unadjusted.
Chowdhary and Patel [23] excluded lifetime suicide and
PLOS Medicine | www.plosmedicine.org
Intimate Partner Violence, Suicide, and Depression
depressive disorder diagnosis at baseline from analyses; howev-
er, this likely resulted in the exclusion of many cases of violence
that preceded suicide attempts or depressive symptoms or
disorder at baseline—the resulting cases of violence being few
and not representative of women experiencing IPV. Nearly all
studies (14 of 16) also controlled for demographic factors, but in
general, other confounders were not comprehensively con-
trolled. Often the estimates included in the meta-analyses, only
two controlled for CSA and/or other early life experiences
[13,22]. None controlled for alcohol use. Of the seven studies
not included in the meta-analyses (those with continuous
measures of depression), 5/7 controlled for demographic factors
[28–31,37], but only 2/7 for CSA [29,30], one for early life
factors [30], and one for early risk behaviour [37]. Despite these
differences in variables controlled for across analyses, there were
no discernible differences in effect estimates: regardless of which
confounders were adjusted for, all studies found similar
directions and varying magnitudes of association. For men
(Table 2), the picture was similar: most studies adjusted for time
one levels of the outcome, but other key confounders were not
adjusted for.
Effect estimates for depressive disorder and symptoms in
women. Of the 16 studies looking at depressive symptoms or
disorder and IPV in women, 13 provided estimates of IPV and
incident depressive symptoms or disorder and six provided
estimates of depressive symptoms and incident IPV (Table 1).
Twelve of 13 estimates showed a positive direction of association
between experience of IPV and incident depressive symptoms,
with 11 reaching statistical significance. All six estimates looking at
depressive symptoms and incident IPV also showed positive
associations, which were statistically significant.
We were able to include all estimates reporting binary violence
measures and binary depressive symptoms or disorder measures in
meta-analyses (Figure 2). For IPV and incident depressive
symptoms or disorder, the pooled OR from six estimates was
1.97 (95% CI 1.56–2.48). This was heterogeneous (I2 = 50.4%,
p = 0.073), although almost all studies had a positive direction of
effect. Removing the outlier (Chowdhary and Patel [23]) did not
improve heterogeneity estimates. Four estimates were included in
the meta-analysis of the relationship between depressive symptoms
and incident IPV, resulting in a pooled OR of 1.93 (95% CI 1.51–
2.48, I2 = 0%, p = 0.481).
Effect estimates for depressive symptoms in men. For
men (Table 2), two studies [27,37] examined experience of IPV
and incident depressive symptoms, and both studies showed a
significant association in a positive direction. Foshee et al.
examined depressive symptoms and time to onset of physical
and sexual victimisation, as well as ‘‘chronic victimisation’’, and
found non-significant relationships in a positive direction
(bivariate model) [26]. Jonsson et al. found that 2.5% of adult
men reporting depressive symptoms as adolescents also reported
adult experiences of IPV, versus 0% of adult men who did not
report depressive symptoms in adolescence [22].
Suicide Attempts
Three studies investigating suicide attempts met our inclusion
criteria [23,27,37]. These studies reported eight estimates of
association of experience of IPV with incident suicidal attempts.
Six were for female populations, and two were for male
populations. Ackard et al. and Roberts et al. both sampled US
adolescents and the IPV measured was dating violence (for both
male and female adolescents) [27,37]. Chowdhary and Patel
sampled a cohort of adults from Goa, India, comprising adult
4 May 2013 | Volume 10 | Issue 5 | e1001439
 Intimate Partner Violence, Suicide, and Depression

Table 1. Summary of studies of depression and IPV, in women.

Effect Estimate
Study; Participants, Country IPV Measure Depression Measure (95% CI), p-Valuea Factors Adjusted For

Time One
Depression CSA Traumab

IPV and incident depression

Ackard et al. [27] (Project Eat); Physical and/or Symptoms, OR = 1.92 (1.22–3.00) Yes (past year at No No
822 adolescents, US sexual, CTS-like ‘‘Kandel and Davies’’ baseline)
scale, time period not
specified
Chowdhary and Patel [23]; Physicalc, CTS-like CIS-R, past year OR = 0.88 (0.26–3.00) Yes No No
1,563 adults, India
La Flair et al. [30]; 1,438 hospital Physical and/or CES-D, past week Beta = 0.65, p = 0.39 No Yes Yes
employees, US sexual, AAS
Levendosky et al. [33]; 150 adults, US Physical and/or BDI, time period not r = 0.24, p,0.05 No No No
sexual, SVAWS specified
Lindhorst and Oxford [31]; 229 young Physical, CTS BSI, past week Beta = 0.23, p,0.001 Yes No No
adults, US
Loxton et al. [20]; 11,648 adults, ‘‘Violent CES-D, past year OR = 2.51 (2.07–3.06) Yes No No
Australia relationship’’, not and/or ‘‘ever
defined diagnosis’’
Newcomb and Carmona [32]; 113 Physical, CTS CES-D, time Path coefficient = 0.17, Yes Yes No
HIV+ and HIV2 Latina women, US period not specified p = 0.05
Rich et al. [29]; 551 Physical and BDI-II, time Correlation = 0.11, Yes Yes Yes
college students, US verbal, CTS period not specified p = 0.05; path analysis =
‘‘not significant’’
Roberts et al. [37] (Add Health); Physical, CTS-like CES-D, time Beta = 0.18 (0.1–0.26) Yes No No
1,659 adolescents, US period not specified
Salazar et al. [24]; 276 adults, Nicaragua Physical and/or SRQ-20, time OR = 2.01 (1.08–3.78), No No No
sexual, CTS-like period not specified p = 0.0178
(WHO)
Suglia et al. [34]; 1,834 adults, US Physical and/or CIDI-SF, past year Adjusted OR = 1.09 Yes No No
sexual, CTS-like (0.6–1.9)
and general
question
Taft and Watson [21]; 9,683 adults, Physical and/or CES-D, time period not OR = 2.12 (1.69–2.65) Yes No No
Australia sexual, CTS-like and specified and ‘‘ever
general question diagnosis’’
Zlotnick et al. [28]; 3,104 adults, US Physical, CTS-like CES-D, past week Beta = 6.96, p = 0.003 Yes No No
Depression and incident IPV
Foshee et al. [26]; 1,965 Physicalb, CTS-like Symptoms, ‘‘Kendler’’ Hazard ratio = 1.35 Yes Yes Yes
adolescents, US scale, time period not (1.05–1.74)
specified
Jonsson et al. [22]; 322 adults, Sweden Physical, one Any symptoms (BDI, OR = 3.47 (1.11–10.84) No Yes Yes
general question CES-D-C, time period
not specified) or
diagnoses (DICA-R-A) or
MINI
Nduna et al. [25]; 995 adults, Physical and/or CES-D, past week Adjusted OR = 1.67 Yes No No
South Africa sexual, CTS-like (1.18–2.36)
(WHO)
Lehrer et al. [13] (Add Health); Physical, CTS-like CES-D, past week Adjusted OR = 1.86 Yes Yes Yes
1,659 adolescents, US (1.05–3.29)
Levendosky et al. [33]; 150 Physical and/or BDI, time period not r = 0.23, p,0.05 No No No
adults, US sexual, SVAWS specified
Salazar et al. [24]; 370 adults, Physical and/or SRQ-20, time period not OR = 2.42 (1.46–4.02), Yes No No
Nicaragua sexual, CTS-like specified p = 0.002
(WHO)

a
p-Value if no confidence interval reported.
b
Other childhood trauma.
c
More than one type of violence measured but only one estimate included here.
AAS, Abuse Assessment Screen; BDI, Beck Depression Inventory; BDI-II, Beck Depression Inventory–II; BSI, Brief Symptom Inventory; CES-D-C, Center for Epidemiologic
Studies–Depression–Children; CI, confidence interval; CIDI-SF, Composite International Diagnostic Interview–Short Form; CIS-R, Clinical Interview Schedule–Revised; CTS,
Conflict Tactics Scale; DICA-R-A, Diagnostic Interview for Children and Adolescents–Revised-Adolescents; MINI, Mini-International Neuropsychiatric Interview; SVAWS,
Severity of Violence Against Women Scales; WHO, World Health Organization.
doi:10.1371/journal.pmed.1001439.t001

PLOS Medicine | www.plosmedicine.org 5 May 2013 | Volume 10 | Issue 5 | e1001439

 Intimate Partner Violence, Suicide, and Depression

Table 2. Summary of studies of depression and IPV, in men.

Effect Estimate
Study; Participants, Country IPV Measure Depression Measure (95% CI), p-Valuea Factors Adjusted For

Time One Depression CSA Traumab

IPV and incident depression

Ackard et al. [27] (Project Physical and/or Symptoms, ‘‘Kandel OR = 1.92 (1.22–3.00) Yes No No
Eat); exual, CTS like and Davies’’ scale,
694 adolescents, US time period not specified
Roberts et al. [37] (Add Physical, CTS-like CES-D, time period Beta = 0.18 (0.1–0.26) Yes No No
Health); 2,237 adolescents, US not specified
Depression and incident IPV
Foshee et al. [26]; 638 Physicalc, CTS-like Symptoms, ‘‘Kendler’’ Hazard ratio = 1.1 Yes No No
adolescents, US scale, time period (0.9–1.36)
not specified
Jonsson et al. [22]; 84 adults, Physical, one Any symptoms (BDI, 2.8% of those with No No No
Sweden general question CES-D-C, time period not versus 0% of those
specified) or diagnoses without depression
(DICA-R-A) or MINI at wave 1 reported
IPV at wave 2

a
p-Value if no confidence nterval reported.
b
Other childhood trauma.
c
More than one type of violence measured but only one estimate included here.
BDI, Beck Depression Inventory; CES-D-C, Center for Epidemiologic Studies–Depression–Children; CI, confidence interval; CTS, Conflict Tactics Scale; DICA-R-A,
Diagnostic Interview for Children and Adolescents–Revised–Adolescents; MINI, Mini-International Neuropsychiatric Interview.
doi:10.1371/journal.pmed.1001439.t002

women only [23]. No studies examined suicide attempts and
incident IPV.
Suicide measures. All studies modelled lifetime suicide
attempts as a binary variable, and assessed attempts with a
single question. No studies had completed suicides as an
outcome.
Common risk factors/confounding. Ackard et al. [27] and
Roberts et al. [37] controlled for time one suicide attempts;
Chowdhary and Patel [23] excluded participants with lifetime
suicide attempts at baseline. None controlled for early life factors,
including experience of CSA.
Effect estimates for suicide attempts in women. Chowdhary
and Patel [23], Ackard et al. [27], and Roberts et al. [37] examined
violence and incident suicide attempts: all three studies showed positive
relationships, of which two were statistically significant and one was of
borderline significance (Table 3).
Effect estimates for suicide attempts in men. Two
studies examined violence and incident suicide attempts
[27,37]: both found non-significant relationships, one in a
positive direction and the other with exactly no association
(Table 4). Both of these studies included adolescent or young
adult US men; both also controlled for time one suicide
attempts.
Discussion
Summary of Main Findings
Our review provides evidence that experience of IPV increases
the odds of incident depressive symptoms and of suicide attempts
among women. We also found evidence that depressive symptoms
can increase the odds of incident IPV in women. However, our
ability to draw firm conclusions is limited by the quality of the
available studies, in particular the lack of adjustment for common
risk factors. Relatively few studies included men, but these studies
suggested a relationship between IPV and incident depressive
symptoms. For men, there was no clear evidence of an association
between IPV and incident suicide attempts, or between depressive
symptoms and incident IPV.
Limitations of This Review
Our review employed extensive searches of global literature in
multiple languages. Despite this, our review has some limitations.
Because of the large volume of search results returned, we were
unable to employ double screening of abstracts, and for our
update, double data extraction. We also did not contact authors
for additional information. The different scales of measurement
(binary or continuous) employed across various studies meant that
we were unable to combine all measures of effect, which limited
the number of studies in our meta-analyses. However, studies that
we could not include in meta-analyses showed a positive direction
of effect consistent with that of the studies included in the meta-
analyses. Too few studies met the inclusion criteria to meaningfully
assess publication bias.
Sources of Bias and Limitations of Included Studies
The main limitation of included studies relates to lack of
comprehensive control of potential confounders. Both IPV and
depression can be conceptualised as chronic episodic conditions,
and most studies controlled for time one levels of the outcome
variable or excluded baseline cases in their analyses. However,
alcohol use and childhood adversity, including early experiences of
violence and trauma, were generally not controlled for, making it
difficult to rule out these other factors as contributors to the
causation of outcomes. We did find that studies generally showed a
positive direction of association regardless of which potentially
confounding variables were adjusted for, and there was also no
clear pattern of differing magnitude of association, indicating that
the relationships between IPV and depressive symptoms and
suicide are not likely to be entirely accounted for by shared risk
factors.
Almost all included studies on depression measured depressive
symptoms rather than major depressive disorder, dysthymia, or

PLOS Medicine | www.plosmedicine.org 6 May 2013 | Volume 10 | Issue 5 | e1001439

 Intimate Partner Violence, Suicide, and Depression

Figure 2. Meta-analyses of the association between IPV and depressive symptoms or disorder in women.
doi:10.1371/journal.pmed.1001439.g002

Table 3. Summary of studies of suicide and IPV, in women.

Study; Participants, Suicide Attempts Effect Estimate

Country IPV Measure Measure (95% CI), p-Valuea Factors Adjusted For

Time One
Suicide Attempts CSA Traumab

Ackard et al. [27] (Project Eat); Physical and/or sexual, Single question, ever OR = 3.2 (0.97–103.59) Yes No No
822 adolescents, US CTS-like attempted suicide
Chowdhary and Patel [23]; Physicalc, CTS-like Single question, ever OR = 7.97 (1.75–36.37) Yes No No
1,563 adults, India attempted suicide
Roberts et al. [37] Physical, CTS-like Single question, ever Beta = 0.12 (0.02–0.22) Yes No No
(Add Health); 1,659 attempted suicide
adolescents, US

All studies measured IPV and incident suicide attempts.

a
p-Value if no confidence interval reported.
b
Other childhood trauma.
c
More than one type of violence measured but only one estimate included here.
CI, confidence interval; CTS, Conflict Tactics Scale.
doi:10.1371/journal.pmed.1001439.t003

PLOS Medicine | www.plosmedicine.org 7 May 2013 | Volume 10 | Issue 5 | e1001439


Table 4. Summary of studies of suicide and IPV, in men.
Study; Participants, Suicide Attempts
Country IPV Measure Measure
Ackard et al. [27] Physical and/or sexual, Single question, ever
(Project Eat); 694 adolescents, US CTS-like attempted suicide
Roberts et al. [37] (Add Physical, CTS-like Single question, ever
Health); 2,237 adolescents, US attempted suicide
All studies measured IPV and incident suicide attempts.
a
p-Value if no confidence interval reported.
b
Other childhood trauma.
CI, confidence interval; CTS, Conflict Tactics Scale.
doi:10.1371/journal.pmed.1001439.t004
other depressive disorders using Diagnostic and Statistical Manual
of Mental Disorders or International Classification of Diseases
diagnostic criteria. Only around one-third to one-half of people
who score above recommended CES-D cutoffs are diagnosed with
major depressive disorder [38,39]. The relationship between
violence experience and depressive disorders may differ from the
relationship between violence experience and depressive symp-
toms. Major depressive disorder has a substantial heritability [40]
and has been shown to be more heritable than less severe forms of
depression [41]; situational causes such as violence may therefore
play a more important etiological role in the less severe forms of
depression. Conversely, experiences of violence may predict more
severe depression and thus have a stronger association with
depressive disorders than with depressive symptoms. When
examining violence in relation to depression, including subthresh-
old depressive symptoms and depressive disorders could either
dilute or inflate effect estimates.
Most studies were from high-income countries, and four were of
adolescents or college students. In high-income contexts, in these
samples, relationships will be primarily in dating relationships. In
dating relationships where there is no cohabitation, there may be a
lower likelihood of chronic exposure to violence within the
intimate partnership [42,43], which may lessen any subsequent
mental health impact. Other studies of the features of intimate
partner abuse have shown that fear, entrapment, and feelings of
inability to escape from violent situations specifically contribute to
increased adverse mental health outcomes [42]—these relation-
ship features are likely to be less pronounced in dating
relationships, which could mean that effects are underestimated
in studies including only adolescents.
Emotional violence, which we did not include here, may also be
an important predictor of adverse mental health outcomes [44].
The epidemiological study of emotional IPV is in its infancy, but at
least one study that has modelled combined measures of physical,
sexual, and emotional IPV has shown a relationship between these
forms of abuse and incident suicide attempts in Indian women
[45].
Most studies also measured exposure only to physical violence,
or modelled exposure to physical violence and sexual violence
separately. Most studies constructed reference categories as binary
opposites, meaning that some participants in the reference group
may have been exposed to other forms of violence by intimate
partners that were not measured or modelled. This approach may
bias the effect estimates towards the null, and underestimate the
magnitude of the association between violence experience and
depression outcomes. Several studies also included only women
who were in relationships for all time points of data collection. The
PLOS Medicine | www.plosmedicine.org
Intimate Partner Violence, Suicide, and Depression
Effect Estimate
(95% CI), p-Valuea Factors Adjusted For
Time One Suicide
Attempts CSA Traumab
OR = 7.55 Yes No No
(0.81 to 70.31)
Beta = 0 (20.6 to 0.6) Yes No No
prevalence of IPV is usually higher in women who no longer have
a partner versus women currently in a partnership (for example,
[46]). Not including these women may bias associations towards
the null. Similarly, it is conceivable that women who are no longer
in a partnership may have higher or lower odds of depression/
suicide attempts. If they are not surveyed in subsequent waves,
associations may be biased in different directions.
Is the Relationship between IPV, Depression, and Suicide
Causal?
Cross-sectional evidence suggests that lifetime experience of IPV
is consistently associated with both SRQ-20 score (representing
probable cases of depression and/or anxiety) [4] and suicide
attempts among women in a range of low- and middle-income
countries [3]. Several studies have shown a dose–response
relationship, where IPV is associated with increased frequency of
depressive episodes [20], and other studies have shown that
depression is more strongly predictive of incident severe IPV than
it is of less severe IPV [13]. Twin studies provide evidence for a
plausible causal mechanism, that exposure to traumatic events,
including sexual assault and violence, can cause increased risk of
depression, ruling out early life confounders [10,18].
Our review presents evidence for a temporal relationship
between IPV experience and depressive symptoms, but also shows
that women with existing depressive symptoms are more likely to
subsequently experience IPV. Our finding is consistent with other
longitudinal studies that have considered combined measures of
IPV perpetration and experience, which found that women with
depression were more likely to be in an abusive relationship, but
also that being in an abusive relationship predicted incident major
depressive disorder [47]. In summary, it seems that the relation-
ship between IPV and depression is bidirectional, with women
who are exposed to IPV being at increased risk of depression
symptoms, and women who report depressive symptoms being
more likely to subsequently experience IPV. For young men, we
found no clear evidence of a relationship between IPV, depressive
symptoms, and suicide, but very few studies included men. Further
studies that include male participants are needed to clearly
establish whether or not there is an association.
Implications
The different forms of depression—major depressive disorder,
dysthymia, and mild depression—as well as suicidal behaviour, are
some of the largest causes of disease burden in women globally.
Our findings suggest that interventions to prevent violence need to
be explored for their efficacy in reducing different forms of
8 May 2013 | Volume 10 | Issue 5 | e1001439

depression. Similarly, for women already receiving mental health
treatments or presenting with symptoms of depression, attention
must be paid to experiences of violence and risk of future violence.
Because IPV often occurs as a pattern of ongoing events [43],
treatment strategies that fail to address womens’ experience of
violence may do harm. For example, if violence is not suspected as
a potential causative factor, patients who have attempted suicide
may be encouraged to return to partners/relatives, which could
increase the risk of further violence and eventual suicide [48].
Anti-depressant medication may also interfere with women’s
ability to make decisions about how to respond to violence [49].
Further research is needed to explore why having depressive
symptoms can lead to incident violence—it may be that young
women with depressive symptoms are predisposed to choose
partners who use violence. Depression can also lead to maladap-
tive coping with stress, cognitive distortions about risk, and loss of
self-efficacy. Young people who have experienced early traumatic
events, including violence in their families, are at higher risk for
poor mental health as adolescents [50]. Longitudinal studies where
both violence exposure and depression are measured at multiple
time points are needed to more clearly elucidate causal
mechanisms. It is clear that addressing the burden of untreated
mental disorders in a population could have substantial effects on
the prevalence of violence.
Conclusion
Interventions to prevent violence should be explored for their
efficacy in reducing the burden of depressive symptoms and
disorders as well as suicide attempts in women. Women who have
References
1. Ribeiro PS, Jacobsen KH, Mathers CD, Garcia-Moreno C (2008) Priorities for
women’s health from the Global Burden of Disease study. Int J Gynecol Obstet
102: 82–90.
2. Garcia-Moreno C, Jansen H, Ellsberg M, Heise L, Watts C (2005) WHO multi-
country study on women’s health and domestic violence against women.
Geneva: World Health Organization.
3. Devries KM, Kiss L, Watts C, Yoshihama M, Deyessa N, et al. (2011) Violence
against women is strongly associated with suicide attempts: evidence from the
WHO multi-country study on women’s health and domestic violence against
women. Soc Sci Med 73: 79–86.
4. Ellsberg M, Jansen HAFM, Heise L, Watts CH, Garcia-Moreno C, et al. (2008)
Intimate partner violence and women’s physical and mental health in the WHO
multi-country study on women’s health and domestic violence: an observational
study. Lancet 371: 1165–1172.
5. Beydoun HA, Beydoun M, Kaufman JS, Lo B, Zonderman AB (2012) Intimate
partner violence against adult women and its association with major depressive
disorder, depressive symptoms and postpartum depression: a systematic review
and meta-analysis. Soc Sci Med 75: 959–975.
6. Deyessa N, Berhane Y, Alem A, Ellsberg M, Emmelin M, et al. (2009) Intimate
partner violence and depression among women in rural Ethiopia: a cross-
sectional study. Clin Pract Epidemiol Ment Health 5: 8.
7. Bonomi AE, Anderson ML, Reid R, Rivara FP, Carrell D, et al. (2009) Medical
and psychosocial diagnoses in women with a history of intimate partner violence.
Arch Int Med 169: 1692–1697.
8. Breiding MJ, Black MC, Ryan GW (2008) Prevalence and risk factors of
intimate partner violence in eighteen U.S. states/territories, 2005. Am J Prev
Med 34: 112–118.
9. Hyde JS, Mezulis AH, Abramson LY (2008) The ABCs of depression:
integrating affective, biological, and cognitive models to explain the emergence
of the gender difference in depression. Psychol Rev 115: 291–313.
10. Kendler KS, Thornton LM, Prescott CA (2001) Gender differences in the rates
of exposure to stressful life events and sensitivity to their depressogenic effects.
Am J Psychiatry 157: 587–593.
11. Khalifeh H, Dean K (2010) Gender and violence against people with severe
mental illness. Int Rev Psychiatry 22: 535–546.
12. McPherson M, Delva J, Cranford JA (2007) A longitudinal investigation of
intimate partner violence among mothers with mental illness. Psychiatr Serv 58:
675–680.
13. Lehrer JA, Buka S, Gortmaker S, Shrier LA (2006) Depressive symptomatology
as a predictor of exposure to intimate partner violence among US female
adolescents and young adults. Arch Pediatr Adolesc Med 160: 270–276.
PLOS Medicine | www.plosmedicine.org
Intimate Partner Violence, Suicide, and Depression
experienced violence may benefit from tailored interventions that
address the changes that come with prolonged exposure to trauma
in order to prevent future depression and suicidal behaviour.
Supporting Information
Text S1 PRISMA checklist.
(DOCX)
Text S2 List of databases searched and example search
strategy.
(DOCX)
Table S1 Details of longitudinal studies included in the
review.
(DOCX)
Acknowledgments
We wish to acknowledge the other members of the Global Burden of
Disease Expert Working Group on Violence, Claudia Garcia-Moreno and
Christina Pallitto.
Author Contributions
Conceived and designed the experiments: KMD CHW. Performed the
experiments: KMD LJB JYM GF JCC. Analyzed the data: KMD MP.
Wrote the first draft of the manuscript: KMD. Contributed to the writing
of the manuscript: KMD LJB JYM GF JCC JA MP CHW. ICMJE criteria
for authorship read and met: KMD LJB JYM GF JCC JA MP CHW.
Agree with manuscript results and conclusions: KMD LJB JYM GF JCC
JA MP CHW.
14. Bifulco A, Kwon J, Jacobs C, Moran PM, Bunn A, et al. (2006) Adult
attachment style as mediator between childhood neglect/abuse and adult
depression and anxiety. Soc Psychiatry Psychiatr Epidemiol 41: 796–805.
15. Doumas DM, Pearson CL, Elgin JE, McKinley LL (2008) Adult attachment as a
risk factor for intimate partner violence: the ‘‘mispairing’’ of partners’
attachment styles. J Interpers Violence 23 616–634.
16. Banyard VL, Williams LM, Siegel JA (2001) The long-term mental health
consequences of child sexual abuse: an exploratory study of the impact of
multiple traumas in a sample of women. J Trauma Stress 14: 697–715.
17. Melhem N, Brent D, Ziegler M, Iyengar S, Kolko D, et al. (2007) Familial
pathways to early-onset suicidal behaviour: familial and individual antecedents
of suicidal behaviour. Am J Psychiatry 164: 1364–1370.
18. Kendler KS, Karkowski LM, Prescott CA (1999) Causal relationship between
stressful life events and the onset of major depression. Am J Psychiatry 156: 837–
841.
19. (2012) The Global Burden of Disease Study 2010. Lancet 380: 2053–2260.
20. Loxton D, Schofield M, Hussain R (2006) Psychological health in midlife among
women who have ever lived with a violent partner or spouse. J Interpers
Violence 21: 1092–1107.
21. Taft AJ, Watson LF (2008) Depression and termination of pregnancy (induced
abortion) in a national cohort of young Australian women: the confounding
effect of women’s experience of violence. BMC Public Health 8: 75.
22. Jonsson U, Bohman H, Hjern A, von Knorring L, Paaren A, et al. (2011)
Intimate relationships and childbearing after adolescent depression: a popula-
tion-based 15 year follow-up study. Soc Psychiatry Psychiatr Epidemiol 46: 711–
721.
23. Chowdhary N, Patel V (2008) The effect of spousal violence on women’s health:
findings from the Stree Arogya Shodh in Goa, India. J Postgrad Med 54: 306–
312.
24. Salazar M, Valladares E, Ohman A, Hogberg U (2009) Ending intimate partner
violence after pregnancy: findings from a community-based longitudinal study in
Nicaragua. BMC Public Health 9: 350.
25. Nduna M, Jewkes RK, Dunkle KL, Shai NP, Colman I (2010) Associations
between depressive symptoms, sexual behaviour and relationship characteristics:
a prospective cohort study of young women and men in the Eastern Cape, South
Africa. J Int AIDS Soc 13: 44.
26. Foshee VA, Benefield TS, Ennett ST, Bauman KE, Suchindran C (2004)
Longitudinal predictors of serious physical and sexual dating violence
victimization during adolescence. Prev Med 39: 1007–1016.
27. Ackard DM, Eisenberg ME, Neumark-Sztainer D (2007) Long-term impact of
adolescent dating violence on the behavioral and psychological health of male
and female youth. J Pediatr 151: 476–481.
9 May 2013 | Volume 10 | Issue 5 | e1001439

28. Zlotnick C, Johnson DM, Kohn R (2006) Intimate partner violence and long-
term psychosocial functioning in a national sample of American women.
J Interpers Violence 21: 262–275.
29. Rich CL, Gidycz C, Warkentin J, Lohc C, Weiland P (2005) Child and
adolescent abuse and subsequent victimization: a prospective study. Child Abuse
Negl 29: 1373–1394.
30. La Flair LN, Bradshaw CP, Campbell JC (2011) Intimate partner violence/
abuse and depressive symptoms among female health care workers: longitudinal
findings. Womens Health Issues 22: e53–e59.
31. Lindhorst T, Oxford M (2008) The long-term effects of intimate partner violence
on adolescent mothers’ depressive symptoms. Soc Sci Med 66: 1322–1333.
32. Newcomb MD, Carmona JV (2004) Adult trauma and HIV status among
Latinas: effects upon psychological adjustment and substance use. AIDS Behav
8: 417–428.
33. Levendosky AA, Bogat GA, Huth-Bocks AC, Rosenblum K, von Eye A (2011)
The effects of domestic violence on the stability of attachment from infancy to
preschool. J Clin Child Adolesc Psychol 40: 398–410.
34. Suglia SF, Duarte CS, Sandel MT (2011) Housing quality, housing instability,
and maternal mental health. J Urban Health 88: 1105–1116.
35. Straus M, Douglas E (2004) A short form of the Revised Conflict Tactics Scales,
and typologies for severity and mutuality. Violence Vict 19: 507–520.
36. Newcomb MD, Munoz DT, Carmona JV (2009) Child sexual abuse
consequences in community samples of Latino and European American
adolescents. Child Abuse Negl 33: 533–544.
37. Roberts TA, Klein JD, Fisher S (2003) Longitudinal effect of intimate partner
abuse on high-risk behavior among adolescents. Arch Pediatr Adolesc Med 157:
875–881.
38. Thomas JL, Jones GN, Scarinci IC, Mehan DJ, Brantley PJ (2001) The utility of
the CES-D as a depression screening measure among low-income women
attending primary care clinics. The Center for Epidemiologic Studies-
Depression. Int J Psychiatry Med 31: 25–40.
PLOS Medicine | www.plosmedicine.org
Intimate Partner Violence, Suicide, and Depression
39. Breslau N (1985) Depressive symptoms, major depression, and generalized
anxiety: a comparison of self-reports on CES-D and results from diagnostic
interviews. Psychiatr Res 15: 219–229.
40. Sullivan PF, Neale MC, Kendler KS (2000) Genetic epidemiology of major
depression: review and meta-analysis. Am J Psychiatry 157: 1552–1562.
41. Lyons MJ, Eisen SA, Goldberg J, True W, Lin N, et al. (1998) A registry-based
twin study of depression in men. Arch Gen Psychiatry 55: 468–472.
42. Browne A (1993) Violence against women by male partners: prevalence,
outcomes, and policy implications. Am Psychol 48: 1077–1087.
43. Johnson MP (1995) Patriarchal terrorism and common couple violence: two
forms of violence against women. J Marriage Fam 57: 283–294.
44. Jewkes R (2010) Gender inequities must be addressed in HIV prevention.
Science 329: 145–147.
45. Maselko J, Patel V (2008) Why women attempt suicide: the role of mental illness
and social disadvantage in a community cohort study in India. J Epidemiol
Community Health 62: 817–822.
46. Nyamayemombe C, Mishra V, Rusakaniko S, Benedikt C, Gwazane M, et al.
(2010) The association between violence against women and hiv: evidence from
a national population-based survey in Zimbabwe. Calverton (Maryland): ICF
Macro.
47. Ehrensaft MK, Moffitt TE, Caspi A (2006) Is domestic violence followed by an
increased risk of psychiatric disorders among women but not among men? A
longitudinal cohort study. Am J Psychiatry 163: 885–892.
48. Stark E, Flitcraft A (1996) Women at risk: domestic violence and women’s
health. Thousand Oaks (California): Sage.
49. Wuest J, Ford-Gilboe M, Merritt-Gray, Berman H (2003) Intrustion: the central
problem for family health promotion among children and single mothers after
leaving an abusive partner. Qual Health Res 13: 597.
50. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, et al. (2001)
Childhood abuse, household dysfunction, and the risk of attempted suicide
throughout the life span. Findings from the Adverse Childhood Experiences
Study. JAMA 286: 3089–3096.
10 May 2013 | Volume 10 | Issue 5 | e1001439

Editors’ Summary
Background. Depression and suicide are responsible for a
substantial proportion of the global disease burden.
Depression—an overwhelming feeling of sadness and
hopelessness that can last for months or years—affects
more than 350 million people worldwide. It is the eleventh
leading cause of global disability-adjusted life-years (a
measure of overall disease burden), and it affects one in six
people at some time during their lives. Globally, about a
million people commit suicide every year, usually because
they have depression or some other mental illness. Notably,
in cross-sectional studies (investigations that look at a
population at a single time point), experience of intimate
partner violence (IPV, also called domestic violence) is
strongly and consistently associated with both depressive
disorders and suicide. IPV, like depression and suicide, is
extremely common—in multi-country studies, 15%–71% of
women report being physically assaulted at some time
during their lifetime. IPV is defined as physical, sexual, or
psychological harm by a current or former partner or spouse;
men as well as women can be the victims of IPV.
Why Was This Study Done? It may seem obvious to
assume that IPV is causally related to subsequent depression
and suicidal behavior. However, cross-sectional studies
provide no information about causality, and it is possible
that depression and/or suicide attempts cause subsequent
IPV or that there are common risk factors for IPV, depression,
and suicide. For example, individuals with depressive
symptoms may be more accepting of partners with
characteristics that predispose them to use violence, or early
life exposure to violence may predispose individuals to both
depression and choosing violent partners. Here, as part of
the Global Burden of Disease Study 2010, the researchers
investigate the extent to which experience of IPV is
associated with subsequent depression and suicide attempts
and vice versa in both men and women by undertaking a
systematic review and meta-analysis of longitudinal studies
that have examined IPV, depression, and suicide attempts. A
systematic review uses predefined criteria to identify all the
research on a given topic, meta-analysis combines the results
of several studies, and longitudinal studies track people over
time to investigate associations between specific character-
istics and outcomes.
What Did the Researchers Do and Find? The researchers
identified 16 longitudinal studies involving a total of 36,163
participants that met their inclusion criteria. All the studies
included women, but only four also included men. All the
studies were undertaken in high- and middle-income
countries. For women, 11 studies showed a statistically
significant association (an association unlikely to have
occurred by chance) between IPV and subsequent depres-
sive symptoms. In a meta-analysis of six studies, experience
of IPV nearly doubled the risk of women subsequently
reporting depressive symptoms. In addition, there was
evidence of an association in the reverse direction. In a
PLOS Medicine | www.plosmedicine.org
Intimate Partner Violence, Suicide, and Depression
meta-analysis of four studies, depressive symptoms nearly
doubled the risk of women subsequently experiencing IPV.
IPV was also associated with subsequent suicide attempts
among women. For men, there was some evidence from two
studies that IPV was associated with depressive symptoms
but no evidence for an association between IPV and
subsequent suicide attempt or between depressive symp-
toms and subsequent IPV.
What Do These Findings Mean? These findings suggest
that women who are exposed to IPV are at increased risk of
subsequent depression and that women who are depressed
are more likely to be at risk of IPV. They also provide
evidence of an association between IPV and subsequent
suicide attempt for women. The study provides little
evidence for similar relationships among men, but additional
studies are needed to confirm this finding. Moreover, the
accuracy of these findings is likely to be affected by several
limitations of the study. For example, few of the included
studies controlled for other factors that might have affected
both exposure to IPV and depressive symptoms, and none of
the studies considered the effect of emotional violence on
depressive symptoms and suicide attempts. Nevertheless,
these findings have two important implications. First, they
suggest that preventing violence against women has the
potential to reduce the global burden of disease related to
depression and suicide. Second, they suggest that clinicians
should pay attention to past experiences of violence and the
risk of future violence when treating women who present
with symptoms of depression.
Additional Information. Please access these websites via
the online version of this summary at http://dx.doi.org/10.
1371/journal.pmed.1001439.
N This study is further discussed in a PLOS Medicine Pers-
pective by Alexander Tsai
N The US National Institute of Mental Health provides
information on all aspects of depression and of suicide
and suicide prevention (in English and Spanish)
N The UK National Health Service Choices website provides
detailed information about depression, including personal
stories about depression, and information on suicide and
its prevention; it has a webpage about domestic violence,
which includes descriptions of personal experiences
N The World Health Organization provides information on
depression, on the global burden of suicide and on suicide
prevention, and on intimate partner violence (some
information in several languages)
N MedlinePlus provides links to other resources about
depression, suicide, and domestic violence (in English
and Spanish)
N The charity Healthtalkonline has personal stories about
depression and about dealing with suicide
11 May 2013 | Volume 10 | Issue 5 | e1001439